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HIV Infection ‘Clusters’ Put Focus on Harm Reduction Programs

Health officials in Huntington, West Virginia, say a cluster of HIV infections has grown to 71 confirmed cases. That’s in a city that usually sees about eight HIV infections in a year. As with an earlier such cluster in northern Kentucky, officials say the primary cause of infection is needle drug use.

Health officials say a harm reduction program is an effective tool against HIV infection. The programs usually offer a syringe exchange, access to addiction counseling, and health screening services such as HIV testing.

The programs have expanded rapidly in the Ohio Valley, a region hit hard by the opioid crisis and at highest risk in the nation of infectious disease outbreaks due to needle drug use.

But many people remain wary of syringe exchanges, and health officials are concerned that a backlash means some programs will close just when they’re most needed. The Huntington cluster of HIV cases appears to be correlated with the controversial closure of a nearby harm reduction program.

“The boomerang effect, the recoil, is going to be if these programs start closing, you’re going to see explosions of blood-borne pathogens, specifically HIV,” said Dr. Michael Brumage, director of the Preventive Medicine Residency Program in the West Virginia University School of Public Health.

High-Risk Region

In 2016 the Centers for Disease Control and Prevention spotlighted the counties in the U.S. at the highest risk of an HIV outbreak. Of the 220 high-risk counties, about a quarter were in Kentucky, West Virginia, and Ohio. The ten counties CDC found at highest risk were all in Kentucky and West Virginia.

Public health officials in the region have been working to implement syringe exchange harm reduction programs, which are widely supported as the most effective tool in combating HIV and other infectious diseases associated with needle drug use.

Dr. Greg Corby-Lee is the strategist with the University of Kentucky’s Harm Reduction Initiative. He said community-based harm reduction programs can be a lifeline to those still using drugs.

“It takes a while for them to build that level of trust up to come in,” he said. “That’s their one bridge, where they can be respected, and be given nothing but help to stay healthy.”

Corby-Lee said HIV prevention is the primary focus.

“That’s what they were designed for. But there are a lot of other benefits that come with it,” he said, such as peer counseling and screening for other diseases, such as Hepatitis C.

HIV/AIDS educator Greg Corby-Lee talking about harm reduction.

Corby-Lee said prevention and testing for HIV are becoming more widely available in the area, and stigma – which can thwart outreach, testing and treatment – is gradually diminishing.

But he and other health officials also worry about a backlash brewing in many communities, threatening the harm reduction programs. They fear that misconceptions about the programs may threaten the very communities at greatest risk of an outbreak.

Daniel Raymond is Deputy Director of Planning and Policy for the National Harm Reduction Coalition. He said that while harm reduction programs are generally expanding, some are closing in the communities where they are needed most. The programs can become the focal point for other problems associated with the addiction crisis, he said, such as litter from used needles, homelessness, and petty crime.

“A lot of these programs have been starting in communities that don’t have a long history with harm reduction,” Raymond said. “So the programs that end up being at risk of closure are often the ones that are getting scapegoated for a community’s drug problem.”

Closure, then a Cluster

Dr. Brumage says that’s part of the problem he encountered when leading a harm reduction program in Charleston, West Virginia. The program ended most of its services last year amid local political pressure and complaints about discarded needles.

“I think it’s a simplistic view to look at and blame one program for all of the city’s woes, with homelessness, with use, with all these other things,” Brumage said. “And I think that’s a trick that many politicians use very well, is to find a culprit scapegoat and to blame it rather than really looking at deeper issues.”

The deeper issue, he says, is that the HIV threat is real and not going away. Less prevention equals more sick people. In Huntington, one person in the HIV cluster has died. However, Brumage is concerned that some Huntington residents are now viewing the cluster of infections as evidence to close its harm reduction program as well.

“Currently, some people in that community are saying, ‘Well, look, we have the syringe program, and we still got HIV, maybe we just need to close the program,’” he said. “The fact that you have a fire doesn’t mean you should close the fire department. You know, you bring more trucks on the scene.”

Brumage worries that the closure of the Charleston program may have contributed to the rise in HIV infections Huntington is now experiencing. The two cities are less than an hour’s drive apart along Interstate 64. And Brumage argues that Huntington’s cluster of infections could be much worse without a syringe exchange in place.

“My guess is had Huntington not had a syringe program, this problem would have exploded far worse.”

Other health officials say the growing HIV cluster in Huntington is a cautionary tale.

“It’s the looming disaster that we were all afraid of,” West Virginia University School of Medicine Professor Dr. Judith Feinberg told Mother Jones magazine.

Signs of Hope

Still, harm reduction proponents remain optimistic. The National Harm Reduction Coalition says that for every program closing, 20 more open. Kentucky has witnessed rapid growth in such programs.

Van Ingram, who leads Kentucky’s Office of Drug Control Policy, said that has only been possible with a fundamental shift in thinking about drug use as a health problem instead of a problem for law enforcement. He admits he was skeptical that the programs could take root in Kentucky. But it’s happening.

Kentucky Drug Control Policy Director Van Ingram.

“I never dreamed we’d have 56 programs,” he said. “I did not think as many communities would have said, ‘Yes, we have a problem, and yes, we’re addressing big issues.’ Those communities are much, much quicker in recognizing the problem than I thought they would. I’m glad to say, I was wrong.”

Bourbon County, Kentucky, is an example of the phenomenon Ingram is describing. After several failed votes the county approved a syringe exchange program last year. Judge Executive Mike Williams said he braced for the complaints and backlash.

“I got gas yesterday afternoon and had three conversations at the gas pump about three different things,” he said, but the syringe program was not one of the things people had concerns about.

Since the syringe program opened, helping about 100 people, he said he’s only heard concerns from three people.

West Virginia Suspends Needle Exchange Program in Capital

West Virginia’s Bureau for Public Health has officially suspended the certification of a harm reduction program following concerns over its needle exchange component.

The Charleston Gazette-Mail reports that the agency suspended the Kanawha-Charleston Health Department’s Harm Reduction Syringe Services Program’s certification following the Friday release of an independent evaluation of the program. That evaluation was requested by Charleston Mayor Danny Jones, who, along with law enforcement officials, accused the needle exchange program of causing an uptick in dirty needles in public places.

The needle exchange portion of the program was suspended in March. The agency’s report calls upon the health department to follow several recommendations if the program is reinstated, including improving data collection.

The health department must reapply to obtain certification again.

Report: Needle Exchange Program Should Lose Certification

An audit requested by a West Virginia mayor who said a needle exchange program had caused an increase of dirty needles in public places has recommended the suspension of the program’s certification.

The Charleston Gazette-Mail reports that a team commissioned by the state Bureau for Public Health submitted a report to Charleston on Friday, saying the Kanawha-Charleston Health Department’s Harm Reduction Syringe Services Program needs to follow a list of recommendations if it’s reinstated. The report emphasized insufficient and inaccurate data collection.

The report was released nearly two months after Charleston Mayor Danny Jones asked for the independent audit and review.

The needle exchange portion of the program has been suspended since late March.

KCHD spokesman John Law says the agency hasn’t been provided a copy of the report.

Surgeon General Supports Needle Exchanges To Limit Disease From Opioid Crisis

U.S. Surgeon General Jerome Adams threw his support behind syringe exchange services as an important tool to address the Ohio Valley’s high risk of needle-borne disease associated with the opioid epidemic.

Adams visited Florence, in northern Kentucky, for an event to encourage more people to get trained to administer the overdose-reversal drug naloxone. Dressed in a full, dark uniform with gold stripes on his sleeves, Adams demonstrated his technique with the potentially life-saving nasal spray.

Adams with Jody Jaggers, Director of Kentucky’s Pharmacy Emergency Preparedness Program.

“Let’s show them how this works,” he told a crowd of health officials and media.

Naloxone training can help address one deadly aspect of the opioid crisis. But Adams’ visit to the Northern Kentucky Health Department also highlighted another: the outbreak of needle borne disease unfolding in the region.

Since January, state and federal health officials have been tracking a growing clusterof more than 40 HIV cases in northern Kentucky associated with needle drug use. It’s the latest evidence of the Ohio Valley’s high risk of disease outbreak associated with the opioid crisis.

An analysis by the Centers for Disease Control found that of the country’s 200 counties at highest risk for HIV and Hepatitis C outbreaks from needle use, roughly half of the counties are in Kentucky, Ohio and West Virginia.

As Indiana’s Health Commissioner, Adams learned how critical is is to properly monitor and contain those outbreaks.

“One of the reasons surveillance is so important is because anyone can be the next Scott County, Indiana,” he said.

Scott County was the scene of a 2015 outbreak of more than 200 HIV cases discovered in just a few months in that small, rural community. Adams managed the response to that crisis. He said the lessons learned from the Scott County outbreak shaped how emerging clusters of HIV are now handled in rural communities.

Adams said it is important to show that needle exchange programs can do much more than the name implies.

“Actually connecting people to care, serving as a valuable touch point to insurance, to testing for other disease,” he said. “We will be much more successful than if they think we are just giving needles to people with a habit.”

He said the focus for health officials is shifting to disease prevention through community-based harm reduction programs.

“We want communities to have a conversation about what their risks are,” he said. “That starts with the data. How many are people are overdosing? What their hepatitis rates are — because hepatitis is a marker for injection drug use. Once we do that we need to have a broader conversation about how we respond.”

Adams said stemming the outbreak in Scott County also showed the importance of broad community support.

“The most common theme that I see are partnerships,” he said. “You have to have support of the public safety community, the business community, and the faith-based community.”

During his visit, Adams met with local health experts including Ardis Hoven, a Kentucky doctor and a former president of the American Medical Association. Hoven said her state is at the epicenter of the problem and can continue to push for solutions.

“Kentucky has actually taken the lead in many of these areas,” she said. “We have much to be proud of, but the important thing is that there is so much work to be done.”

Exchange of Ideas: How A Rural Kentucky County Overcame Fear To Adopt A Needle Exchange

Greg Lee, Kentucky’s HIV/AIDS educator, starts the town hall on a somber note.

“How many people in this room know someone who has died of an overdose death?”

It is a standing-room only crowd. Most hands go up.

“Amazing,” he says, sadly.

The meeting is at the Bourbon County Public Health Department, just next to the county’s drug rehab center and down the hill from a playground where used needles are found far too often.

For two-and-half-years there has been fierce opposition and two failed votes over a needle exchange here. On this evening, the key players are gathering one more time for a third debate on the needle exchange proposal.

Mike Williams, judge executive of Bourbon County, has been pushing for a needle exchange since state legislation made it an option in Kentucky. Bourbon County was the first rural county, following Louisville and Lexington, to attempt to start an exchange. After the failed attempts, he hoped 2018 would be different

“I was determined there was going to be a vote,” Williams said.

Cecil Foley, longtime magistrate, represents the most rural parts of the central Kentucky county.

“I was dead against it, to be honest with you,” Foley said of the needle exchange.

Joe Turner is the founder of Recovery Warriors, a group that works for addiction treatment.

“I knew going into the meeting it was going to be an uphill battle,” he said.

In addition to the toll of overdose deaths, the Ohio Valley now also has some of the nation’s highest-risk areas for outbreaks of needle-borne disease such as HIV and Hepatitis C. Health experts say a needle exchange is a strong defense against both overdose and disease. But exchange programs face strong public opposition, particularly in culturally conservative communities.

Which way would Bourbon County go?

“Handouts” or Help?

A skeptical tone dominates the early discussion in Bourbon County’s meeting. One audience member says, “I see those people all over dumpster diving, they’ll just take the needles and sell them to their friends.”

Lee pushes back and says the exchange is provided to prevent that. The woman is unconvinced. “I don’t think it will,” she says.

Others in the audience say addicts are just looking for a handout.

But amid the skepticism there is sympathy as well. When Magistrate Foley uses the word “druggies” some in the audience push back.

“If we are enabling druggies to break the law, that’s illegal,” Foley says.

“These people aren’t druggies, they are human beings,” a man in the audience booms in response, followed by applause.

Foley said later that moment caught him off guard.

“I was surprised, to be honest with you, that they came back so hard,” he said in an interview after the meeting. “I know they are human beings. I’ve a nephew who is in jail right now for using drugs.”

.As the meeting continues, Turner, wearing a ball cap and a black “Recovery Warrior” T-shirt, makes his way to the microphone.

“I’ve been arrested more times than I’d like to admit by some of the very people in this room,” he says, drawing some knowing laughs.

That was before he got clean five years ago, he said. Now Turner’s helping others, including Foley’s nephew. He said he connects up to 10 people a week with treatment. His phone rings constantly as people ask for help.

Turner tells the audience that the people he works with don’t want the life of an addict.

“They want help,” he says. “They will bum a ride, they will take a bike, they will hot foot it to come here and get a clean needle. They beg me for help.”

Health experts laid out how quickly needle-borne diseases can spread and how often people can have full-blown AIDS before ever getting tested. Lee talks about how much it costs to treat cases of HIV and Hep C and how that cost falls to the taxpayers. The price of prevention is far lower.

Difficult Decisions

The difficult discussions over needle exchange programs are happening across the Ohio Valley. Public health officials, increasingly alarmed by disease outbreaks and the unrelenting toll of overdoses, promote needle exchange programs as a way to reduce harm, encourage addiction treatment, and offer disease testing services.

The 2015 HIV outbreak in Scott County, Indiana, which was fueled by needle drug use, is fresh in the minds of many public health practitioners. More recently, outbreaks in southern West Virginia and northern Kentucky have renewed concerns, and the Centers for Disease Control has identified many counties in the region as at high risk for disease.

But the health facts run up against deeply held opinions about the moral aspects of drug use and the notion that a needle exchange enables drug addicts to continue harmful behavior.

Some opposition is rooted in religious convictions. Some is based in fear that an exchange will draw addicts from the surrounding region and bring what was considered an urban problem to a small town.

Seach for needle exchange programs with our interactive map >>

Even some places that have established needle exchanges are now reconsidering, worried that such programs bring crime into their communities or that local efforts are helping people from other counties or states. Charleston, West Virginia, recently suspended its needle exchange program amid criticism and pressure from the city’s mayor.

But by and large, needle exchange programs have expanded rapidly in the past two years in response to the opioid crisis. At the end of 2016, there were 30 needle exchange programs in Kentucky, Ohio and West Virginia. By the end of 2017, the region established nearly 40 additional exchanges, more than half of which are located in CDC at-risk counties.

Ten more exchanges have already opened their doors in 2018. Ten more exchanges are slated to open in the coming months in Kentucky alone, bringing the total to 46 Kentucky needle exchange locations.

Personal Tragedies

For about an hour the Bourbon County meeting is adversarial, with little common ground apparent. The meeting’s tone starts to shift in hour two as folks like Magistrate Don Menke share personal tragedies.

“My brother-in-law died, overdose. My nephew just died, was missing for a week,” he says. “They found him in a hotel room. Overdose.”

At least five people rise to say they have a relative who is addicted or who has died. Judge Williams says he’s been to the funerals of the children of five friends since he first proposed the needle exchange more than two years ago.

A Bourbon County playground where used needles often show up.

“Those funerals are real,” he says. “That pain is real.”

At this point, Magistrate Foley seems to be having second thoughts about his opposition. But, he says, a needle exchange is still a tough sell for his constituents.

“I’m going to need your help,” he says to the room. “Where I live out in the county, nobody is in favor of a needle exchange. Y’all are going to have to help me tell this story that I heard here tonight.”

The room goes silent as Judge Executive Williams calls for the vote.

All eight magistrates cast their ballots. Foley votes, “Yes.”

There is a pause while the tally is made. The final vote: 6 to 2 in favor.

“The measure passes,” Williams says to thunderous applause.

What Works

In follow-up interviews, Foley, Turner and Williams, still all a little surprised at the outcome, reflected on why the measure was approved.

Foley said that if more people heard the whole story behind an exchange program, they would change their minds like he did.

“It’s more of a safety issue and it’s meant to stop the spread of disease and to save money.”

Turner said it’s crucial that support is homegrown.

“Most people from small, rural towns, they don’t like outsiders,” he said. “It’s got to be grass- roots.”

Bourbon County Judge Executive Greg Williams listens to comments on the needle exchange.

Williams said he was jubilant at the outcome. But it was hard to tell from reading his face during the meeting. He said he didn’t want to react too much because he knew many people still were strongly opposed. He offered this advice to other community leaders: Persevere.

“It took us three times,” he said. “Don’t give up, and keep presenting the facts.”

The Bourbon County needle exchange program begins operating in May.

Needle Exchange Rules Tightened in W.Va. City

A West Virginia police department has tightened rules for a health department’s needle exchange program.

Charleston Police Chief Steve Cooper said Monday participants must present a government-issued identification before receiving any needles from the Kanawha-Charleston Health Department. He also ordered only retractable needles to be issued and for participants to undergo blood tests and be offered drug counseling.

The move comes after Charleston Mayor Danny Jones said too many needles are ending up on playgrounds and streets.

In a letter, Cooper also said the health department must submit monthly reports listing participants, including those who have entered a rehabilitation program and who have tested positive for HIV or hepatitis infections. The reports also must include the number of needles both distributed and returned.

Kanawha County Commissioner Kent Carper called Cooper’s initiative a “common sense approach.”